Summary: Some integrative medicine leaders view the patient centered medical home (PCMH) as an optimal environment for expressing an integrative practice. Obama's Affordable Care Act included specific language that invited operators of PCMHs to include chiropractors, and licensed complementary, alternative and integrative practitioners. An exceptional resource in this area is Tom Trompeter, MHA, the CEO of Healthpoint. The 12 center network, formerly the Community Health Centers of King County, is not only quite advanced in its development of what Trompeter prefers to call a "patient-centered healthcare home." For 15 years, Healthpoint has included diverse natural medicine offerings such as acupuncture, naturopathic medicine, massage therapy and behavioral health care. Trompeter offers his reflections on the nature of the PCMH paradigm and what it asks of both practitioners, and those who would educate them for participation in this emerging model.

First in an Integrator series on CAM/IM and the patient centered medical home.

Healthpoint's Sea-Tac Center: Patient Centered Healthcare Home

Google Healthpoint and you see this banner: "Medical and Dental Care, Natural Medicine, Community ..." This high-level advertisement of natural medicine integration in a large community health operation distinguishes the network of now 12 federally-qualified community health centers. Then enter Healthpoint's site and click "Services." One is greeted with a teasing "All the services you expect ...." next to an arrow button. Click the arrow and you read: "And a few you probably don't." Then this message.

"Healthy communities begin with healthy people. We provide primary
medical and dental services, as well as complementary and alternative
services distinguished by exceptional quality and accessibility. We
serve patients from all walks of life, regardless of their ability to
pay. We also serve the community through outreach, an on-site medical
school for community health physicians, and more."

This unusual service mix is offered in an organization that is committed to the patient-centered medical home (PCMH) model. Formerly the Community Health Centers of King County (CHCKC) , Healthpoint has over 450 employees and a $40-million operating budget. It serves a population of 65,000 people each year.

TomTrompeter, MHA, Healthpoint CEO

Healthpoint's CEO,Tom Trompeter, MHA, prefers to call the Healthpoint approach a "patient-centered health care home." Trompeter has headed up the organization since shortly after it became nationally known 15 years ago through a partnership with Bastyr University. The partnership, initiated by Trompeter's CHCKC mentor Jane Leed, won a $1-million state grant competition to originate the first publicly-funded natural medicine center in the nation. Through Trompeter's leadership, Healthpoint continued expanding this integration through employed natural healthcare practitioners long after the grant funds were exhausted.

I spoke with Trompeter recently as part of a multi-part Integrator examination of the potential of the PCMH (or PCHH) as a context for enhancing and flourishing an integrative medicine model. In this interview, Trompeter invites practitioners to adopt a new way of thinking. He urges educators to train students differently so they will be prepared to participate optimally in this emerging model. The former director of the Northwest Regional Primary Care Association has also been a member of the board of directors of the National Association of Community Health Centers. He plays a nice saxophone. Here is the interview.

________________________________

Integrator: So, how are you at Healthpoint looking upon this national movement toward the patient-centered medical home (PCMH)? Does it make sense for you?

Trompeter: You bet. Let me be clear that we are about being a healthcare home, not a medical home. We are better positioned than most because we are already better organized for the PCMH. Two years ago we went through the NCQA-sponsored training. We realized we were already 70% of the way there. By virtue of our status as an FQHC [Federally Qualified Health Center] over 50% of our Board of Directors are patients. We have a necessarily patient-centered view. We have an electronic health record. It's part of our strategic plan to get NCQA certification.
[Integrator: You speak of a healthcare home. What distinguishes a healthcare home from a medical home in your mind?

Pioneering an integrative PCMH model

Trompeter: We do more than a medical come. We do dental. We already have PhD psychologists in all of our clinics. We have the complementary and alternative medicine services. If you define medical home narrowly, you leave out the CAM services. We are all about population health management. Our providers think about panels of patients, about working as parts of teams. We try to be, to use a well-worn word, holistic. The medical doctors and dentists interface. We're a little more integrated than most medical practices.

Integrator: Section 3502 of the Affordable Care Act specifically states that in medical home pilots that chiropractors and other licensed complementary and alternative medical providers may be included as part of teams. The language is "may" not "shall." Is there much awareness of this piece of the law in the community health center community?

Trompeter: Broadly speaking, probably no.

"To break the paradigm of the private
physician
practice we have a team approach,
with everyone working at the top of
their license.
This opens the door to greater diversity."

Integrator: So what about in your own centers?

Trompeter: Well, we have had naturopathic doctors, acupuncturists, nutritionists, massage, and groups for 15 years. Integrator: What about chiropractors?Trompeter: There hasn't been a lot of thought about the chiropractic side here. The initial steps with any of these disciplines are hard. When we started with NDs, there was a lack of familiarity. Horror stories tend to come to the mind of conventional providers and vice versa. With chiropractors, there are the questions about the relative value of chiropractors versus other disciplines such as physical therapists. At some point some frank conversation should occur. Integrator: How do you think the medical home, the healthcare home, supports more rather than less use of CAM practitioners?

Trompeter:The PCMH needs to be all about primary and preventive care. We approach this from a couple of angles. We need the right workforce to adequately care for the size of the population we have here, whether they are rich and insured or poor and uninsured.To break the paradigm of the private physician practice we have a team approach, with everyone working at the top of their license. This opens the door to greater diversity. What does the best team look like? Who brings what skills to what tasks to manage the population we serve? That is the question a provider or provider group need to be asking.Integrator: That's a fascinating orientation. It's not: Take me, here's the revenue I can generate. It's not: Take me, here is the new client I can draw. It's really about how can all that the provider has be best shaped to work in and with your team for the aims you describe, of primary care and prevention.

Trompeter: No one profession has all the tools in the tool box. We start speaking differently in the PCMH. We think about the organization of service delivery. Then we think about who can do best what we need. There is no cookbook. This opens the door to think really differently about who is doing what for whom. Professionals need to think differently. The "my patient" needs to transition to "our patient."Integrator: Well, bring this home now for the integrative and CAM community.

Trompeter: We're still working on it. With the NDs the question is often "who is a PCP" since NDs can be primary care providers in Washington. I'd say about that question, which is a big one for the naturopaths: Does it really matter in a PCMH? The question has caused us to think differently about our panels of patients here. Do they belong to individuals -- whether MDs or DOs or NDs - or to teams? We don't have answers. We're not there yet. We like to think of patients aB as belonging to teams.Integrator: For many reasons being designated and used as a primary care provider is huge to the naturopathic profession.

Trompeter: Our experience is that this has often broken down to being more about the billable visit than about the patient. We need to be rewarding contributions that improve the health of people. That may or may not be under the primary care designation for NDs. Think about the social determinants of health that are at the center of Clem Bezold's work with primary care. If you shift your lens that way, there is an entirely different way of doing one's work with a population.

Integrator: You have an electronic medical record. How do the NDs and acupuncturists work with this?

"We believe that this movement is toward
seeing healthcare more as a public utility
than an entrepreneurial enterprise."

Trompeter:They are full participants. We've tooled our EMR to capture all of our services from all our providers. The EMR is really more about the patient than the provider. The data are all about the health of the patient. . Integrator: Say more about the differences in this model, and how providers need to envision their own role differently.

Trompeter: The PCMH is not only breaking the paradigm of whose patient it is, and whether the patient belongs to a person or a team. It's also about getting beyond the billable visit. Our model is toward having employed and salaried practitioners as opposed to independent entrepreneurs who, out of business necessity, focus on the production of billable events.

Integrator: I recall that famous article Atul Gawande wrote at the height of the Obama reform debate. talking to salaried Mayo doctors, one of them said that with employed physicians you not only limit the incentive to churn, you also create an environment more conducive to teamwork and appropriate referral.

Trompeter: We believe that this movement is toward seeing healthcare more as a public utility than an entrepreneurial enterprise.

Integrator: You have been a community health center activist since the early days.

Trompeter:The National Association of Community Health
Centers has been called the largest primary care system in the
country. We are all organized around similar principles. We are not-for-profit. We each have a patient majority on our Board of Directors. This is huge. Their participation keeps us much closer to the business at hand. The requirement empowers people from the community. They have a better understanding of what is needed. There are those who question this. They say, but, you know, you have all those resource decisions to make and yet you have all these low-income people on your board. I can tell you from my experience, when it comes to decisions about resources, these patients are right on it. They get our mission.

Trompeter: Learn to work in cross-disciplinary teams. Marry your work with a heart for social justice. We had a recent event with a local Congressman. He likes to talk about "the heart of a servant." In so many branches of health care we have failed to educate about the heart of a servant.

Integrator: Any additional comments? What do you say to the evidence barriers that are sometimes held up to block inclusion of CAM providers?

Trompeter: The whole notion of what is evidence is another discussion. It's commonly said that there is only a strong evidence base for some 20% of what we do. Generally speaking, in a comprehensive primary care setting, when the economics are more organized around producing healthy people, what any practitioner needs to do is look at what gives us the effect that we are trying to cause. And that is, to have a healthier populations. Start with that and that will be the interesting conversation.

Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......more

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